The University of Chicago

PEDIATRIC EMERGENCY DEPARTMENT CLINICAL GUIDELINE:

Oral Antifungal Drugs & Indications

Tinea capitis Griseofulvin (ultramicrosize) 15 mg/kg/day 412 weeks 20-25mg/kg/day x 8 weeks Ketoconazole (Nizoral) NR Fluconazole (Diflucan) 50 mg qd 3 weeks 6mg/kg/day x 4 wks Itraconazole (Sporanox) 3-5 mg/kg/day 4-6 weeks 4-5mg/kg/day Terbinafine (Lamisil) 125 mg qd (3-6 mg/kg/day) 4 weeks <20kg 62.5mg qd 20-40kg 125mg qd >40kg 250mg qd some say best dose may be about 4.5mg/kg/day x 6-8wks 250 mg qd Fingernails 6 weeks Toenails 12 weeks <20kg 62.5mg qd 20-40kg 125mg qd >40kg 250mg qd at least 6 wks for fingers, 12 wks for toes 250 mg qd 6 weeks Studies ongoing

Onychomycosis Tx only recommended when culture proven; discontinue when culture negative

500-1000 qd 6 to 18 months not really recommended

NR

150 mg once a week 9 months I dont know anyone who uses this

200 mg qd fingernails 6 weeks Toenails 12 weeks Pulse dosing 200 mg bid 1 week on, 3 weeks off, Toenails 3-4 months, Fingernails 2-3 months 400 mg qd 4 weeks 200 mg qd 5 or 7 days

Tinea pedis Systemic generally not recommended Tinea versicolor

500 mg/qd adult 5-7 mg/kg/day child 6-12 weeks Not effective

NR

150 mg once a week 3-4 weeks 400 mg single dose 300mg q wk x 23 wks 150 mg single dose

Vaginal candidiasis

Not effective

400 mg single dose or 200 g/day 5-10 days I prefer 400mg single dose, rpt in 1 wk 200-400 mg qd 5 days

200 mg tid one day or 200 mg qd 3 days

Studies ongoing

* Adapted from Clinical Dermatology, Habif, 1996, p 388-9.

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Oral Antifungal Drugs & Indications

Dosage forms Griseofulvin (ultramicrosize) 125, 250, 333 mg ultramicronized tablet - 125 mg/5 ml food enhances absorption NO 2 weeks 1 to 2 weeks Rx 6 weeks complete blood count (CBC) liver function test (LFT) 8% to 15% Multiple uncommon side effects Abdominal Pain, erythema, multiforme, headache, mixed drugs reactions, nausea and vomiting, photosensitivity, urticaria Alcohol, barbiturates, coumarin, oral contraceptives, warfarin Ketoconazole (Nizoral) 200 mg tablet taken with breakfast with an acidic fruit juice NO 2 days Unknown Baseline CBC, LFT; repeat each month 13% Fulminant hepatotoxicity in 1/10,000 Abdominal pain, nausea and vomiting, dizziness, fever, headache, pruritus, inhibition of testicular and adrenal steroidogenesis Alcohol, antacids, astemizole, coumarin, cyclosporine, erythromycin, H2 antagonists, isoniazid, phenytoin, rifampin, sulfonylureas, terfenadine $232 / 100 pills Fluconazole (Diflucan) 50, 100, 200 mg tablets water soluble, well absorbed Itraconazole (Sporanox) 100 mg capsule food enhances absorption Terbinafine (Lamisil) 250mg

Fungicidal Persistent in plasma after Rx Persistent in skin and nails after Rx Laboratory monitoring

NO --3 months Baseline CBC, LFT; repeat each month

NO I week 6 to 9 months Baseline CBC, LFT; repeat each month 7% Less hepatotoxicity than ketoconazole Nausea and vomiting, abdominal pain, hypokalemia, increased aminotransferase activity, dizziness, headache, pruritus, rash, sleepiness Astemizole, carbamazepine, coumarin, cyclosporine, digoxin, erythromycin, H2 antagonists, isoniazid, Phenobarbital, phenytoin, rifampin, sulfonylureas, terfenadine $139 / 30 pills

YES 4 to 6 weeks 4 to 6 weeks CBC, repeat each month

Adverse reactions Safety Profile

7% Les hepatotoxicity than ketoconazole Abdominal pain, nausea and vomiting, headache, rash

5% Few side effects; minor GI disturbances Nausea and vomiting, abdominal pain, dizziness, headache, pruritus, rash, taste loss

Adverse reactions

Potential drug interactions

Coumarin, cyclosporine, hydrochlorothiazids, isoniazid, oral contraceptives, phenytoin, rifampin, sulfonylureas, valproic acid

H2 antagonists, rifampin, cyclosporine

Cost to pharmacist/pill

$90 / 100 pills

$173 / 30 pills (100mg)

Available in 1995 or 1996 in the US

* Adapted from Clinical Dermatology, Habif, 1996, p 388-9.